Carotid
CAS

TIA in bilateral severe carotid disease

An 84-year-old man with a complex cardiovascular history, including prior TAVI and chronic kidney disease, presented with sudden-onset dysarthria. 

Imaging revealed an occluded left internal carotid artery and a subocclusive stenosis of the right internal carotid artery.

How should this critical bilateral carotid situation be managed?

Paolo Sbarzaglia
Paolo Sbarzaglia
Cotignola, Italy
Part I - Case presentation

Our patient is an 84-year-old man.

Cardiovascular Risk Factors

  • HTN
  • Former smoker

Medical history

  • 2007 → partial gastrectomy for gastric cancer, without chemotherapy or radiotherapy
  • 2024 → chronic myeloproliferative syndrome under clinical follow-up
  • Chronic kidney disease → stage 3b (GFR 40 ml)

Cardiovascular history

  • 2019 → TAVI for severe aortic valve stenosis
  • May 2025 → sudden onset of dysarthria → neurological diagnosis of TIA → supra-aortic trunks duplex ultrasound: sub-occlusion of RICA (PSV 4.8 m/sec) associated with suspected complete occlusion of LICA

Supra-aortic trunks angiography

Occlusion of the left internal carotid artery
Subocclusive stenosis of the right internal carotid artery

What will happen next?

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Part II - Final strategy

How to select EPD

Posterior circulation provides adequate collateral circulation to middle cerebral artery.

→ Let’s go for a proximal flow blockage embolic protection device (Mo.Ma)

Mo.Ma implantation and stenting

0.035’’ Terumo wire in RECA
Supracore + Mo.Ma in RECA
Advancing and delivering carotid stent (7.0 – 30 mm)
Advancing and delivering carotid stent (7.0 – 30 mm)

Post-dilatation and final result

Post-dilatation 5.5 x 20 mm balloon. Occlusion time: 4:31 min

To summarise…

  1. This very complex case was suitable for endovascular treatment, as it was possible to safely treat it with carotid stenting and embolic protection device.
  2. An embolic protection device is pivotal in carotid stenting and, in this case, we managed to implant Mo.Ma device because of an adequate intracranial circulation coming from vertebral arteries.
  3. Because of severely hypoperfused RICA, we implanted Carotid WALLSTENTTM because of its solid predicatibility in release and plaque coverage. The need to use a small size stent was considered a contraindication to ROADSAVER™.